Pharmacist-Led Transitions of Care Reduced Hospital Readmission Rates for Medicare and Medicaid Patients

Introduction: A patient's understanding, implementation of, and adherence to hospital discharge instructions are important in keeping them from being readmitted to the hospital within 30 days of discharge. The understanding of and ability to follow these instructions after the transition from hospital to home may be significantly supported by additional follow-up interactions by healthcare professionals. Programs supporting this crucial time in a patient's health outcomes have been described as Transition of Care Management (TCM). This study evaluated the impact of pharmacist-led TCM on all-cause 30-day readmission rates among Medicare and Medicaid (CMS) patients. Methods: This retrospective chart review included adult CMS patients from a family medicine residency's primary outpatient clinic who were admitted to area hospitals between August 2021 and December 2022. The pharmacy team attempted to provide TCM services 292 times. The team (pharmacist, pharmacy residents, and students) phoned the discharged patients within 48 hours to discuss discharge instructions and assistance needs, and to schedule a TCM appointment with the patient's physician. The pharmacy team notified the interdisciplinary care team members to ensure comprehensive services would be provided. Data analysis examined three cohorts: those who were contacted and who received TCM, those who could not be reached, and those who were contacted but refused TCM services. The interventions were tracked and assessed together with patient readmissions. Subsequent evaluation compared those who received services to those who did not. Chi-square and descriptive statistics were applied to determine the result's significance (p< .05). Logistic regression was conducted to investigate associations between receiving TCM and 30-day readmission while controlling for demographic variables. Results: Patients who received pharmacy-led TCM were less likely to be readmitted within 30 days of discharge (16.9%) than those who did not (34.7%, p = 0.008). The most common pharmacist interventions were medication reconciliations (98.5%, n = 140), medication education (80.3%, n = 114), and disease state education (43.6%, n = 62) During the medication reconciliation there were discrepancies noted among 79.6% of the encounters in the intervention group. Conclusion: Pharmacist-led TCM interventions and follow-up appointments significantly reduced 30-day readmission rates for adult CMS patients.